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Healthcare Success Stories

Infectious Disease Prevention

Airborne/Ventilation Compliance Strategy Benefits

Joint Commission/CMS/State ventilation focus

Ventilation Compliance Process

Education and Collaboration

Risk Assessment and Space/Systems Inventory

Compliance Testing, Measurement & Verification

Correction of Deficiencies – Remediation/Plan for Improvement

Closing the Loop – Reporting & Documentation, Process review

USP-797 & 800 Cleanroom Assessment, Design/Budget/Build/Certify

Infection Control Construction Plan

Intro’s

Infectious Disease Prevention

Financial Implications

CMS Changes in Reimbursement for HAIs

The Centers for Medicare and Medicaid Services (CMS) promulgated regulations

commencing October 1, 2008, which deny payment for selected conditions occurring

during the hospital stay and are not present on admission. The new CMS policy involve

healthcare-associated infections (HAIs), which are a common expensive, and often

preventable cause of inpatient morbidity and mortality. Approximately 2 million patients per

year develop HAIs, or about 5% of acute hospital admissions. The last decade alone has

seen an estimated 36% increase in HAIs. The estimated 100,000 deaths per year

associated with HAIs rank this as the sixth leading cause of death in the United States. In

a recent study capturing additional underlying expenses, the excess hospital cost of HAIs

across the nation was estimated to be between 28 and 45 billion dollars annually.

Infectious Disease Prevention

Airborne/Ventilation Compliance Strategy Benefits

Decreased Healthcare Associated Conditions

Maintain high level of Patient Quality care

Increased Healthcare Worker Safety

Maintain Revenues

Clinical alignment

Reduction of operational costs with increased efficiencies

Standardized Process & Reporting

Intro’s

Healthcare – Unique Value Proposition

Remediate Budget Build

Education

Assessment

Business Strategy

Consulting

Certification Compliance

Commission

Design

Healthcare

Unique Value Proposition

Energy Efficiency

Healthcare • Infection Prevention/Control Ventilation Compliance

• Pharmacy Cleanroom Solutions

• New Construction ICRA support

Healthcare Success Stories

Lab/Healthcare successes….

Services Provided: • $6.9M cGMP Cell Therapy Processing Facility

Class 5/100 Cleanroom

• Pharmacy Cleanroom Design/Budgeting

• Isolation Room Certification Program

• AAALAC accreditation service

• Test & Balance Services

• Laboratory Controls Repair/Upgrades

• Fume Hood Repair

Systems Included: • Laboratory controls, isolation containment pressure and HVAC fan systems

Healthcare successes….

• Ventilation Compliance Services

• OR directional airflow remediation

• OR monitoring and unoccupied

control setback

• HEPA filter

Assessment

Housing replacement

Leak Challenge testing

• Pharmacy Cleanroom -

design/build/certification

• GI Lab remediation

Healthcare successes….

RESURRECTION MEDICAL CENTER Contact Name:

Rose Marie Semar, RN BSN IP

Tony Marsh – Director of Safety

Joe Betuzzi – Manager, Plant Operations

Brandon Hendler

Services Provided: Airborne Infectious Isolation Room (AIIR)

- Renovation (Design/Build), Certification & Exhaust System Upgrade

Comprehensive Ventilation Compliance Services

Proposed remediation & monitoring systems

Proposed Pharmacy Cleanroom USP<797> Compliant (Design/Build)

Comprehensive Test & Balance Services

Systems Included: Isolation containment pressure system and HVAC fan systems, CRC

Personal Testimony: "Since implementing CEPro's comprehensive ventilation compliance program, Joint Commission inspections have gone smoothly

because of CEPro's remediation plan and detailed report keeping. CEPro's staff is very polite & personable, which is very important

while working on the nursing floors/units of RMC"

Perfect application for Hybrid OR’s renovation with set back functionality: energy efficiency – ($’s in savings and

incentives)

Professional Organizational involvement Third party….

Infection Transmission Routes

• Airborne

• Surfaces

• Water

Healthcare facilities are very complex and evolving!

CDC – Airborne

Droplet transmission

Airborne Transmission - CDC

Accreditation & Certification

documentation & support

…….accreditation and certification is recognized nationwide as a

symbol of quality that reflects an organization’s commitment to

meeting certain performance standards

…..improve health care for the public, in collaboration with other

stakeholders, by evaluating health care organizations and inspiring

them to excel in providing safe and effective care of the highest

quality and value.

…..Up 10% from last year

• Education and Collaboration • IP/C Risk Assessment & Inventory

• Senior management support, IP/C Team • Assessment and Identification of Critical Function Space & Systems • EOC virtual tour with ATG

• Compliance Testing • FGI – Facilities Guidelines Institute design criteria • Accreditation issues – current/future • Resources, tools & process • Data Management

• Correction of Deficiencies – Remediation/Plan for Improvement • Design/Budget/Build - documented action plan • Energy efficiency • New Construction/Renovation ICRA process

• Closing Loops - Documentation, Process review

Developing a Comprehensive IP/C Ventilation Compliance Strategy

•

Environment of Care – Function Space &

Systems Inventory & Risk Assessment

Environment of Care – Function Space &

Systems Inventory & Risk Assessment

CEPro knows: Standards & Compliance

The Guidelines documents began as General Standards published in the Federal Register on February 14, 1947, as part of the

implementing regulations for the Hill-Burton program. The FGI Guidelines for Design and Construction of Hospitals and

Outpatient Facilities recommends minimum program, space, risk assessment, infection prevention, architectural detail, and

surface and furnishing needs for clinical and support areas of hospitals, rehabilitation facilities, and ambulatory care

facilities. The document also addresses minimum engineering design criteria for plumbing, electrical, and heating, ventilation, and

air-conditioning (HVAC) systems, the latter by incorporating ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities.

The Joint Commission, many federal agencies, and authorities in 42 states use the Guidelines either as a code or a

reference standard when reviewing, approving, and financing plans; surveying, licensing, certifying, or accrediting

facilities; or developing their own codes.

Function Space Inventory

& Testing Criteria

FIELD TESTING & DATA GATHERING, COMPLIANCE INVENTORY & DOCUMENTATION TOOLSET

Identify Ventilation Systems Critical Failure points

Environment of Care – Function Space &

Systems Inventory & Risk Assessment

HEPA Filter Certification • Overall System Design &

Risk Assessment

• Airflow velocity

• Airborne Particle Count • Volumetric Filter Leak Test

• Scanning

• Documentation

• NAFA Certification

• Energy efficiency

The photometer is a particle

counter that is used to calculate

the efficiency of a ventilation

installation with HEPA filters.

Building Automation data collection…..CALIBRATION

during data gathering!

Documentation

Documentation

Documentation

Environment of Care

Compliance Testing Summary

….example of supply air

short cycled to exhaust not

providing a complete

washing of the room

Correction of Deficiencies

Design/Budget/Build

Remediation - Plan for Improvement

Non-Compliance

Design/Budget/Build

Remediation - Plan for Improvement

CEPro knows State rules/regulation….

Division of Professional Regulation

The mission of the Division of Professional Regulation is to serve, safeguard and promote

the health, safety and welfare of the public by ensuring that licensure qualifications and

standards for professional practice are properly evaluated, applied and

enforced……Pharmacy Practice Act Rules that will require compliance with USP 797 &

800

Infection Control Construction Plan

• Customize to your organization by ICRA team consensus – Baseline data from IC/P Ventilation Compliance Plan – Daily IC monitoring process – Post construction data comparison

• Documentation! Documentation! Documentation! • Suggest use based upon IC precautions • Required for Classes III & IV • Outlines steps required

– Project parameters – Sign-off

Temp/RH

Differential Press

Noise

CO2

Vibration

HEPA Filter

Real Time ICRA monitoring, baseline alarming

Volumes and Volumes of

Certification/Compliance data

and drawings

updated annually at minimum.

A Unique Value Proposition for Healthcare

Ventilation Compliance Platform

• Cost reduction, value add, less time in critical function space

• Integration with current space use, planning & cost allocation, Environment of Care process

• On-the-spot uploading of remediation compliance drawings/data for immediate accreditation resolution

• Predictive comparatives to past years

• Expansion into all certification/ compliance processes

• Trending analysis, charting, and history reporting

• Big Data….

Enjoy the beautiful Great Lake

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773-580-4401

bill.middleton@ceproinc.com

Hospital’s Foundations fund raising